If You Want People to Stop Smoking, Show Them Their Neighbors Think it’s a Bad Idea

INSIGHTS :  Aug. 3, 2015 HEALTH

A new study suggests that where people live and who their neighbors are, could affect their likelihood to smoke while pregnant, despite health risks.

Burning cigarette

A new study suggests that where people live and who their neighbors are, could affect their likelihood to smoke while pregnant, despite health risks.

Maternal smoking while pregnant is a double-whammy for health consequences.

In addition to the standard health concerns facing adults who smoke is a whole set of additional consequences that can affect the vulnerable fetus.

The particularly dangerous nature of maternal smoking has made the topic a prominent focus of recent discussions, most notably in the ongoing federal Healthy People 2020 effort.

In order to properly understand maternal smoking, public health officials must look at the issue through a contextual lens, according to earlier research by Carla Shoff and T.C. Yang, a pair of Pennsylvania State University-trained demographers. Specifically, they argue that where a pregnant woman lives – and the characteristics of the community to which she is exposed – shapes her likelihood of smoking while pregnant.

In a new paper to be published in September’s Social Science & Medicine, I argue that there are clear ways that social acceptability – a type of peer pressure – affects whether a pregnant woman is likely to smoke.

My work builds upon previous research, which shows that women living in economically disadvantaged counties are more likely to have smoked during pregnancy than women who live in counties with higher socio-economic status.

Moreover, the literature suggests that women living in counties with higher concentrations of black and Hispanic residents have a lower likelihood of smoking during pregnancy. I say more about this initially counterintuitive association below.

These relationships are especially interesting because both exist even when controlling for a slew of personal variables such as the woman’s race and ethnicity, education, age, marital status, and whether this was her first pregnancy.

Researchers are well aware of a “protective” role that a community with a higher socioeconomic status bestows on people, regardless of their own socioeconomic status. Living in a wealthier community can offer advantages in everything from health to education to employment, even to individuals living there who are not themselves financially well off.

But scholars are still trying to learn more about a different type of “protective” effect that causes lower rates of smoking for people – regardless of their own race – living in areas with higher concentrations of black and Hispanic residents.

Notably, this effect of black and Hispanic concentration does not extend to educational or economic outcomes. The uniqueness of these protective relationships to the smoking context provides helpful clues as to what explains them. Specifically, scholars argue that, as a result of the lower prevalence of smoking among blacks and Hispanics, those communities deter others – even those of a different race – from smoking themselves (see Nkansah-Amankra 2010; Shaw and Pickett 2013).

This argument can be connected to broader ideas about the role of social acceptability – essentially, groupthink – when it comes to smoking. Generally speaking, individuals who live in places that are less accepting of smoking (or are even perceived to be) are less likely to smoke themselves.

The idea is that if someone is thinking about smoking, she’s more likely to actually do it if the people around her are smoking as well. And the reverse is true too. It is a social interaction that we see playing out in other activities, especially those related to obesity like eating habits and physical activity (Ajilore et al. 2014; Daly et al. 1993; Hruscha et al. 2011).

Adding to the pre-existing evidence, my research shows that the odds of a woman smoking while pregnant are higher when she lives in a county that is near other counties with higher maternal smoking rates. This research is based on new data analysis techniques that allow us to test simultaneously for how place and space – the relative position of people and places – are involved.

Why does this research matter?

It suggests that if you are near other people who engage in a behavior, the odds that you’ll engage in it also go up.

The first law of geography is that near things are more similar than far things. What we often have trouble understanding is whether that similarity is because places simply share characteristics or because a social process diffuses across space. This study suggests the latter is happening.

Granted, my results are not conclusive evidence that social acceptability is a major factor in smoking decisions. But it is one logical explanation for why smoking in one county relates to the odds of maternal smoking in a neighboring one.

But what do we do with this information? How do we create initiatives and policies aimed at addressing perceptions of social acceptability?

Program developers may consider public service announcements that emphasize different groups’ perceptions of maternal smoking. One type of message could feature quotes from both everyday people and celebrities about how the behavior concerns them. Those messages are a key component of health campaigns in Europe (Rennen et al. 2014). A message indicating how unpopular an activity is may carry more weight than a message strictly about health consequences.

Alternatively, we could let norms follow policy. Research suggests that the stronger implementation of a smoke-free policy in Uruguay compared to Mexico contributed to a social environment that reduced public smoking and subsequent exposure to secondhand smoke (Thrasher et al. 2009).

The good news is that interventions based on the idea of social acceptability should be self-perpetuating. Once healthy norms are established, the health behaviors of the next generation are more likely to reflect those norms. The interventions fuel a cycle.

However, a word of caution: social acceptability approaches should not and cannot be a means to impose one set of beliefs on others. Taking this approach would require the identification of carefully researched benefits of a behavior that could not be obtained through other means

The social acceptability framework has the potential to be a powerful intervention tool. And with that power comes great responsibility, so we need to use it wisely.

For more information on how the study was conducted, click here.


Ajilore, O., Amialchuk, A., Xiong, W., & Ye, X. 2014. Uncovering peer effects mechanisms with weight outcomes using spatial econometrics. Social Science Journal 51(4): 645-651.

Daly, K. A., Lund, E. M., Harty, K. C., & Ersted, S. A. 1993. Factors associated with late smoking initiation in Minnesota women. American Journal of Public Health 83(9): 1333-1335.

Hruschka, D. J., Brewis, A. A., Wutich, A., & Morin, B. 2011. Shared Norms and their Explanation for the Social Clustering of Obesity. American Journal of Public Health 101(S1): S295-S300.

Nkansah-Amankra, S. 2010. Neighborhood contextual factors, maternal smoking, and birth outcomes: multilevel analysis of the South Carolina prams survey, 2000-2003. Journal of Women’s Health 19(8): 1543-1552.

Shaw, R. J., & Pickett, K. E. 2013. The health benefits of Hispanic communities for non-Hispanic mothers and infants: another Hispanic paradox. American Journal of Public Health 103(6): 1052-1057.

Shoff, C., & Yang, T.C. 2013. Understanding Maternal Smoking During Pregnancy: Does Residential Context Matter? Social Science & Medicine 78(2013): 50-60.

Heather O'Connell
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